Colonoscopy Information & Quality | Digestive Health Associates

Colonoscopy is our most important tool in the fight against colon cancer

Unfortunately, it has a serious problem - inconsistent quality. While colonoscopy is now widely available in the United States and around the world, studies have shown that there is marked variation from one facility and doctor to another in the quality of the procedure that is performed.

A patient may assume, if he or she was well treated by the staff and physician and had a comfortable exam, that a high-quality procedure was provided. Sadly, it may have actually been a "bad" colonoscopy and failed to provide the protection from colon cancer that would have resulted from a "good" colonoscopy.

The colorectal cancer screening and prevention benefits of colonoscopy can only be fully realized when it is performed in a high-quality manner.

What is Colonoscopy?

Colonoscopy is an examination of the colon, also called the large intestine, which is the last 5-6 feet of the intestinal tract, ending in the rectum. The examination is performed with a long flexible and steerable tube (colonoscope) which is about the diameter of a finger.

The tip of the tube lights the interior of the colon and projects a color image on high definition video monitors. A variety of instruments may be passed through the colonoscope, allowing the doctor to sample tissue, remove small growths, and perform a variety of treatments.

Why is Screening Important?

Colon cancer is the second leading cause of cancer-related death. Most people with early colon cancer feel perfectly well. Fortunately, early colon cancer can be detected by colonoscopy at early stages, before it has spread outside the colon. Early stage colon cancer is often highly curable.

More importantly, the common growths (polyps) from which most colon cancers may slowly arise can be detected and removed during a colonoscopy, resulting in the potential prevention of colon cancer.

Experts believe that colon cancer deaths may be up to 90% preventable by regular colonoscopy, and that colon cancer itself may be up to 70% preventable.

All individuals should undergo colon cancer screening at or before the age of 45.

Anatomy of the colon (from the National Cancer Institute)

What Defines a High-Quality Colonoscopy?

The U.S. Multi-Society Task Force on Colorectal Cancer has defined a high-quality colonoscopy to depend on the following elements:

Appropriate training and experience

Proper documentation of risk assessment

Complete exam to the cecum with adequate mucosal visualization and bowel preparation

Ability to detect and remove polyps safely

Documentation of polypoid lesions and methods of removal

Timely and appropriate management of adverse events

Appropriate follow-up of histopathology findings

Appropriate recommendation for surveillance or repeat screening based on published guidelines

"Colonoscopy is what we in medicine call a highly 'operator dependent' procedure. That is, some doctors are not only better than others at doing colonoscopy, they are a lot better. Stated in reverse, some doctors are really bad at doing colonoscopy. Virtually every study that has looked for evidence that some people are better than others has found it, and the differences between doctors in how many precancerous polyps they find varies by 4- to 10-fold."
- Douglas K. Rex, MD in the New York Times 2009

"Patients who want the best results should pick an outstanding colonoscopist"
- New York Times editorial, December 19, 2008

Our Quality Performance

Is colonoscopy at Southwest Endoscopy in Durango better than at other facilities? Yes! Our performance is superior to that of our national peer group for the most important generally accepted quality indicators.

2016 Quality Comparison: Southwest Endoscopy Center vs. GIQuIC National Consortium

Quality Metric	Southwest Endoscopy Center (2016)	GIQuIC Consortium (2016)
Colonoscopies performed	2,029	1,547,472
Adenoma Detection Rate (Conventional adenomas only)	38.8%	37.4%
Adenoma Detection Rate (Including serrated lesions)	44.7%	39.4%
Adequate Bowel Preparation	99.0%	94.8%
Photodocumentation of the cecum (Screening colonoscopies)	99.5%	97.3%
Photodocumentation of the cecum (All colonoscopies)	99.5%	96.7%
Average Withdrawal time	10.6 minutes	8.3 minutes

Our peer group is comprised of over 4,000 endoscopists practicing in over 500 U.S. endoscopy facilities. GIQuIC participants voluntarily report their procedure data and monitor their comparative performance - this group likely represents the best performing endoscopists in the United States.

What These Data Mean and Why These Measures Matter

Adenoma Detection Rates

The adenoma detection rate (ADR) is generally accepted to be the single most important current quality measure by gastroenterologists performing screening colonoscopy. Studies have shown a near-linear inverse relationship between an individual colonoscopist's ADR and the frequency with which interval cancers arise in his or her patients.

In a widely reported New England Journal of Medicine paper, each 1% increase in ADR above 20% was associated with a 3% reduction in colorectal cancer incidence and a 5% reduction in colorectal cancer-related mortality.

Ask your doctor about his or her adenoma detection rate.

Adequacy of Bowel Preparation

High-quality colonoscopy requires adequate bowel cleansing. Unfortunately, up to 20-25% of colonoscopies in some studies are reported to have inadequate bowel preparation. Adverse consequences of inadequate bowel preparation include lower adenoma detection rates, longer procedural time, lower cecal intubation rates, and increased risks.

Ask your facility about the quality of its colonoscopy preps.

Photodocumentation of the Cecum (Cecal Intubation Rate)

Colon polyps and the cancers that may arise from them form in all sections of the colon. A complete colonoscopy is one that reaches and fully examines the cecum. A colonoscopy that fails to reach the cecum is incomplete and will fail to detect lesions in the unexamined areas. The ability to perform a complete colonoscopy is a well-accepted measure of a colonoscopist's technical skill.

Ask your doctor about his or her cecal intubation rate.

Average Withdrawal Time

While it might seem that a fast colonoscopy is a good one, the opposite is true. Once we reach the cecum we begin a meticulous examination of the entire colon lining, looking behind each fold, which takes time. Withdrawal times that are short have been associated with both a low adenoma detection rate (meaning a high miss rate) and a higher rate of interval colon cancers.

Ask your doctor how fast he or she withdraws the instrument.

What We See During Colonoscopy

Normal Colon

Photograph of normal descending colon. Complete cleansing of the colon is critical to ensure an optimal examination. This photograph shows the results of a good quality bowel preparation.

What is a Polyp?

Polyps are common growths which develop on the interior lining of the colon. The term "polyp" is commonly used to describe colon lesions which are often raised growths projecting from the colon surface but may also be elevated and flat or even depressed in shape.

Some polyps, particularly those known as adenomas or adenomatous polyps, develop as a result of genetic mutations. While such polyps are benign (not malignant or cancerous) they have the potential to acquire additional mutations over time and become malignant. The process of cancerous change is typically slow (5-10 years) and only occurs in a small minority of at-risk polyps.

Polyps are generally removed as soon as they are detected during the performance of a colonoscopy, to prevent progression to cancer.

Pedunculated (mushroom-shaped) tubulovillous adenoma with high grade dysplasia - removed with cautery snare

Nonpolypoid superficial elevated (flat) adenoma - removed with endoscopic mucosal resection

Flat Lesions and Advanced Detection

As shown in this illustration, potentially premalignant growths (adenomas) are seen in a variety of shapes and sizes. The most elevated lesions are easiest to detect and remove. Flat adenomas and depressed adenomas are less common, carry greater risk of malignant transformation over time, and are more difficult to detect.

With high quality colonoscopy, these flat adenomas can be detected and removed. We are very aware of these lesions at the Southwest Endoscopy Center and we take great care to detect them during every examination.

Colon Cancer - Early Detection Saves Lives

National Cancer Institute graphic showing the stages of colon cancer progression

Early colon cancer in the ascending colon - treated with surgery, no chemotherapy needed. Patient cancer-free 8+ years later.

Advanced colon cancer obstructing the cecum - required surgery and chemotherapy

Prevention of colon cancer, by the detection and removal of potentially premalignant polyps, is the best approach. Failing prevention, the detection of colon cancer at an early and curable stage is the key to an optimal medical outcome.

Preparing for Your Colonoscopy

A clean colon is essential for a safe and effective colonoscopy. If the doctor encounters residual waste material during a colonoscopy it may be necessary to stop the procedure before it is completed, and retained waste may hide serious problems, such as flat polyps or cancers.

Colon Cleanse Instructions

Our standard preparation uses a split-dose method for optimal results:

Eat normally until 6:00 PM the evening before (avoiding seeds and fibrous foods)
Start drinking prep solution at 6:00 PM (drink half the jug - 2 liters - in less than 2 hours)
Take two laxative tablets (bisacodyl 5 mg)
Drink the remaining solution the next morning (complete at least 2 hours before arrival)
Nothing by mouth for at least 2 hours before your procedure

Tips for Easier Preparation

Use a straw placed far back in your mouth to bypass taste buds
Suck on lime wedges after each glass
Refrigerate the solution
Use moist cleansing wipes for comfort
Stay near a restroom once diarrhea begins

What Happens on Procedure Day

Check-In (45 minutes before)

Arrive at least 45 minutes before your scheduled time for registration, changing into a gown, pre-procedure nursing assessment, IV placement, and physician assessment. Your family member or friend is welcome to stay with you during this time.

Sedation & Procedure

Once ready, a nurse anesthetist will administer sedation under the doctor's direction. The colonoscopy usually takes about 15 minutes of actual procedure time. Most patients sleep through their procedure and have no recall of it.

Recovery & Discharge

You'll recover briefly in your preparation area. Most patients are ready to be discharged home about 20 minutes after the procedure is completed, after reviewing the written procedure report with our nursing staff.

After the Procedure

Most patients feel a little bloated, relaxed, and relieved. Eat a light meal to start with and take it easy. You may resume most activities right away, though driving should be restricted until the following day. Normal bowel function typically returns within 1-3 days.

Common Questions

I have a family history of colon cancer. When should I get checked?

Individuals with a close relative who has had colon cancer, particularly at a young age, are at increased risk and should be examined at a younger age and more often than individuals without risk factors.

High risk: First-degree relative with cancer diagnosed at age < 60, or two first-degree relatives - Begin at age 40 or 10 years younger than earliest diagnosis; repeat every 5 years

Increased risk: First-degree relative with cancer at age > 60, or two second-degree relatives - Begin at age 40

When do I get my results?

Your full procedure report will be completed by your gastroenterologist and reviewed with you by our nursing staff at discharge. If any tissue (biopsies, polyps) was removed, it will be examined by a pathologist. Your gastroenterologist will contact you with these results, typically in 7-14 days.

Do I need antibiotics if I have a heart condition or artificial joint?

Heart conditions: No. The American Heart Association guidelines state that prophylactic antibiotics are not recommended for patients who undergo GI procedures.

Artificial joints: No. The American Society for Gastrointestinal Endoscopy (ASGE) has concluded that antibiotic prophylaxis for patients with prosthetic joints is not recommended for colonoscopy.

Why wasn't a large polyp removed during my screening?

We remove at least one polyp in over half of the screening colonoscopies we perform. Over 80% of these polyps are small (< 10mm). While we remove the majority of large polyps encountered, some may be left in place for removal at a later date if special advanced endoscopic or surgical techniques are necessary.

Safety & Potential Risks

While colonoscopy provides very important health benefits of early cancer detection and cancer prevention, there are potential risks. Fortunately, for most patients these risks are far outweighed by the benefits.

Doing nothing and taking your chances with colon cancer is itself a risky proposition. Far more people would be harmed by avoiding colon cancer screening than by undergoing colonoscopy by an experienced gastroenterologist at a dedicated facility.

Complication Rates (Per 1,000 Exams)

National averages based on published research:

Bleeding requiring hospitalization: 1.5 per 1,000
Bleeding requiring transfusion: 0.8 per 1,000
Perforation: 0.16 per 1,000
Diverticulitis requiring hospitalization: 0.3 per 1,000
Hospitalization for any colonoscopy-related cause: 0.2 per 1,000
Splenic injury (damage to the spleen, often in the region of the splenic flexure): Extremely rare - approximately 1 in 3,300-5,000 (0.02-0.03%)

A "national published" rate is not singularly accepted for splenic injury, but a reasonable current estimate lies between 0.02% and 0.03%.

Digestive Health Associates' complication rates are far below these national averages, reflecting our commitment to safety, quality, and exceptional patient care.

When to Contact Us Immediately

If you experience any unexpected symptoms after your examination, contact us immediately:

Bleeding or black/bloody bowel movements
Increasing abdominal pain or tenderness
Fever or chills
Vomiting

Call (970) 385-4022 - If after hours, press option 6 for our on-call doctor

What You Can Do to Ensure a High-Quality Colonoscopy

Do Your Colon Cleanse Properly

This is the most difficult and important part of getting ready for your exam. It is critical that you do your part properly, so that we can provide you with the best examination possible.

Pick an Expert Doctor

A well-trained gastroenterologist is the best doctor to perform your colonoscopy. Gastroenterologists undergo more extensive training in endoscopic procedures than doctors in any other specialty, and they devote a majority of their practice to performing colonoscopy.

Schedule at an Expert Endoscopy Facility

A well-trained and experienced staff and dedicated facility systems are essential. Avoid facilities in which colonoscopy seems to be a sideline activity. Ask to see evidence of the facility's quality improvement program.

Return for Your Next Exam When Advised

Follow your doctor's recommendations for surveillance colonoscopy based on your findings, family history, and other factors. Most patients with normal results return every 5 years.

Colonoscopy Information